Ophthalmology Transcription Services - Sample

HISTORY OF PRESENT ILLNESS: The patient comes in today complaining of three days of cough to the point where she coughs and then she feels short of breath at the end of coughing. She denies any chest pain. She denies any pain at all. She states that she has been healthy otherwise. There is no fever. She does smoke. She takes six to seven cigarettes daily when she has alcohol in the evening. The patient has been healthy otherwise and has no known drug allergies. She states that she is out of her albuterol inhaler. She normally takes albuterol inhaler and states that it makes her feel a lot better, but she just ran out of it a couple of days ago. These symptoms have been going on now for two to three days and other members of the family have the same symptoms. She denies any other symptoms at this time. She has had no recent travel, no calf pain, and no other significant past medical history other than acute bronchitis.

REVIEW OF SYSTEMSThe 12-point review of systems are performed and negative, otherwise, as noted above.

PHYSICAL EXAMINATION

GENERAL: This is a pleasant 40-year-old female patient. The patient appeared well otherwise.
VITAL SIGNS: Reviewed. Blood pressure is 126/69, pulse is 102, respirations are 16, temperature is 97.4, and her oxygen saturation on room air is 100%.

HEENT: Head is normocephalic and atraumatic. Extraocular muscles are intact. Oropharynx is pink and moist. Oropharynx is pink and moist. It is nonerythematous and nonedematous.

LUNGS: Slight amount of inspiratory wheeze and expiratory wheeze noted at the left middle lobe region, not heard at the right side. Otherwise, lungs are clear to auscultation with good inspiratory and expiratory effort noted.

DIAGNOSTIC IMPRESSION

Reactive airway.

Upper respiratory tract infection.

DISPOSITION: The patient had DuoNeb here in the office. After DuoNeb, she feels "100% better." Lungs are now completely clear to auscultation bilaterally. The patient is given a prescription for Proventil HFA one or two puffs by mouth every four to six hours as needed, maximum of 12 puffs in a day. The patient is in agreement with this plan. If any difficulty breathing, return. The patient is agreeable with this plan. The patient states that after her breathing treatments, she feels much better at this time.